Provider Demographics
NPI:1013262435
Name:WALLACE IVY, LEIGH E (CRNA)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:E
Last Name:WALLACE IVY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LEIGH
Other - Middle Name:E
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:205-297-9411
Practice Address - Street 1:810 SAINT VINCENTS DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1601
Practice Address - Country:US
Practice Address - Phone:205-939-7143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-093252367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered